Unwrapping paruresis
From what is known
to
what we still need to know
Alex Gardner
Personal
position
Known to others
Known to self
OPEN AREA
Not known to others
HIDDEN AREA
INFORM OTHERS
Not known to self
LISTEN
TO
OTHERS
BLIND AREA
RESEARCH
You can pee if
You are on your own
Very likely
PARURESIS
But not in the
presence of others..
Or imagined others
Paruresis can range from
Slight and transient
through to
Extreme and
very debilitating
It can cause considerable
bladder problems if not treated
I keep six honest serving-men
(They taught me all I knew);
Their names are
What and Why and When
And
How and Where and Who.
Rudyard Kipling
At the outset it is important to clarify
The difference between
Failure to Pee due to:
Organic factors
Marked by a difficulty
to urinate on demand
even at Home
when alone
Psychogenic factors
Marked by the inability
to pee in the presence
of others…..
But OK at home
The Secret Phobia?
DSM IV 300.23 classified this as a social phobia
and because of the excessive secrecy,
it was also known as the secret phobia.
7% *of the population are believed to be affected.
That is about 4 million paruretics in the UK
It affects both men and women and prevents them
using public toilets or urinating in their
own home when others are present.
Now considered to be a Social Anxiety Disorder
this change has implications for treatment
A 1997 social phobia sub-analysis done at
Harvard Medical School from the 1994
National Co-Morbidity Study indicates that
6.7% of a RANDOM sample of people( U.S.)
said that they have difficulty using a public toilet
away from home.
A Canadian study of Social Phobia in community surveys
in Winnipeg, Manitoba, and Alberta showed that
of (N= 1956) respondents, 9.1% (N=178)
said yes to fears of "using toilet away from home.”
(Archives of General Psychiatry, Nov. 2000)
McCullough (2000) usefully makes the distinction
between
Primary paruresis
the inability to urinate around others,
Secondary paruresis
the importance and meaning we assign
to our primary paruresis.
Guilt
Anxiety
Shame
Low Self Esteem
Helplessness
these result in avoidant behaviours with fears of
misfires, humiliation, ridicule
and overall secrecy
Stage 1
The inability to urinate due to unknown factors
…
but most likely to be a combination of
psychological /neurological ones
giving rise to the PRIMARY PARURESIS
This is the shutdown of the sphincters thus
blocking of the Urine Flow
It is involuntary and outwith persons control
Chocking or Shutdown
Self-consciousness has been shown to be a contributing
factor of choking in athletes.
Situationally self-relevant performance cues had greater
influence on highly self-conscious individuals
than those with low self-consciousness.
For the paruretic individuals, this would apply to
perceived scrutiny by others in the restroom
Social anxiety research shows that for some people
the primary arousal factors are
psychological manifestations of self-consciousness and fear
(Heckelman & Schneier, 1995).
Stage 2
Development of profound emotional
psychological components such as guilt
shame anxiety etc
Thus giving rise to the SECONDARY
paruresis.
Any hesitancy in urination is not seen as
normal but as a confirmation of ones own
inadequacy
Stage 3
These deep seated psychological factors,
perhaps as a result of a learning curve similar to
the development of known accepted phobic
states, produces an avoidant reaction with
greater anxiety.
I would call this TERTIARY paruresis
characterised by avoidant behaviours reinforcing
the primary and secondary events
It is different from other phobic states in that the
avoidance does bring feelings of security by
withdrawal
Perception of threat
FEAR
ON OFF
Disappointment
Avoidance of threat is reinforcing
RELIEF
OFF ON
Hope
People with AP would believe that in the
toilet setting and in proximity to other
people (or belief that others might be
present)
the best way to cope with the pressures
was to avoid:
a) busy restrooms,
b) urinals. Taking a choice of stalls if there
is a real pressing need, even then there
may be problems
c) standing in the stall and hence sitting
down to urinate etc
These and other strategies could be seen
as avoidant behaviours
This avoidant response gave rise to the early
belief that AP was a phobia, and the belief that
it must be treated like other phobic states.
This error in thinking is perhaps why certain
therapeutic approaches did not work well. (eg
hypnosis)
Reviewing the evidence confirms that this is
more likely to be a Social Anxiety Disorder
Failure to speak about it gave the term the
Secret Phobia
Stage 4
as a result of all of the above it can give rise
to feelings of being abnormal and the further
shame/guilt makes them fail to communicate
the problem or seek help.
the excessive hiding away of the issues is
again a well recognised component of AP.
Parurectics
• will not tell partners or friends
• will not attend social functions
• may avoid certain work situations
• will not go on holiday
• attend theatre
• become secretive about their actions
• become skilled at keeping their secret
Deception
Secrecy
Act of commission Act of omission
Sets up
False beliefs
Evades
True beliefs
Therapy
SECRECY
releases
Thought
suppression
Thoughts
hyper accessible
enhances
Thought
Intrusion
After Wegner
Ironic processes
Private self-consciousness is a primary factor
in urination breakdown and provides a stronger
argument than the anxiety model does.
The self-consciousness ‘freezing’ model is based
on the choking under pressure model of behaviour
breakdown.
It centres on attentional shifts from pressure
inducing environmental cues (judgement/fear at the
urinal) to the self, creating increased levels of
private consciousness and self-ruminating
thoughts.
The pressure to micturate rapidly increases and
attention is directed to its complex processes.
However, the harder an individual tries the less
chance there is of success
IDENTIFICATION
(Past)
Physical/Sensory
Cognitive
Affective
ORIENTATION
(Present)
Needs
Attitudes
Beliefs
ANTICIPATION
(Future)
Personal
Social
Interactional
REAL
WORLDS
Real Worlds1 Prof A.Gardner
APPROACH
AVOIDANCE
APPROACH
AVOIDANCE
AVOIDANCE
APPROACH
Real Worlds1 Prof A.Gardner
Hesitancy is not
unexpected
Failure
is
expected
The more there is
FAILURE
The more is it
EXPECTED
Because of the secrecy surrounding paruresis
little is formally known and
research is very difficult to undertake
So “ evidence” is from anecdotal sources and
one internet research (Gibbs 2001)
Of the 4 million people affected Males/females
Are in the ration 9/1
t oile t
possible
w alk
s ay
w or k
situation
pe e
toilet
loca l
go
first
ow n
happe n
come
tak e
try
time
ano ther
can
then
fear
pr oble m
pee
difficult
f eeling
w ait
w ill
many
gr
eat
social
unable
public
s
go
step
myself
ur in al
life
find
other
able
life hav e
cu bicle
cont rol
cons cious
be
f eeling
think
secret
condition
k now
be lie ve
time
do
no
man
he lp
o nly
don
m ay
bla dder
me
ye ar
i
m a ke
get
pr oblem
all
syndr ome
po sting
docto r
any
friend
w ife
da
Three reported times for onset;
a.Infant age 3 – 5
b.Early teens age 11-15
c.adult
Gibbs (2004) study of Avoidant Paruresis (AP)
is the first one ever carried out on this condition and
the perceptions of people with AP.
N=264 adult paruretic males aged 18 –80
completed a global, anonymous Internet survey
over a 4 month period in 2004.
Participants were invited to complete the survey on
line accessing the questionnaire on paruresis advice
web sites. These were mainly in the USA Europe and
Australia.
Men’s health and university web sites were also used.
Gibbs constructed the Paruresis Severity
Questionnaire (PSQ) specifically for this research
The six self-report measures were used
Paruresis (PSQ)
Specific Social fears (SPSQ)
Private self-consciousness, (RRQ)
Specific social anxiety, (SCS
Generalised social anxiety, (SIAS)
and the Big Five personality traits. (BFI)
Personality profile of paruresis (Gibbs 2004)
1. Compared to community norms
(A) men were significantly higher on:
•INTROVERSION
Introspection/ socially withdrawn
•NEUROTICISM
Nervous and anxious
•CONSCIENTIOUSNESS Reliable; attention to detail
•PRIVATE SELF CONSCIOUNESS
a) Rumination
Negative self evaluation
b) Reflection
Positive self interest & awareness
(B) Men scored within normal range on;
•OPENESS
•AGREEABLENESS
Pleasant, kind, trustworthy
Public self consciousnessconcern over other’s scrutiny
Personality profile of paruresis (Gibbs 2004)
2. Paruresis and Social Phobia
Paruresis outcomes are consistent with social phobia diagnosis as follows
1. Anticipatory fears of needing to pee in public
2. Avoidance behaviour is present (fear of restrooms)
3. Concern over scrutiny of others (fear of restrooms)
4. Onset in adolescence
5. Tendency to worry, be oversensitive, easily embarrassed
Personality profile of paruresis (Gibbs 2004)
6. Often related to a specific event
e.g Bullying teasing at school urinals etc.
NOT consistent with social phobias
A) Normal levels of trait like scrutiny of others (PubSC)
B) Excessive tendency to self-focus
C) Introversion
Personality profile of paruresis
The results suggests that Paruresis is an unique form of
Social Anxiety Disorder consistent with men who are
articulate, sensitive, functional, talented and
not excessively anxious
However the inability to undertake the natural process of
peeing, when in the presence of another, can be an
extremely debilitating phenomena. Stresses can build up
The consequential personal, family, social and vocational
deficits render living with paruresis very difficult
PSQ Individual Items: Frequencies for Psychosocial and
Psychosomatic Issues, and Perceived Etiology of Paruresis
Personal experience
_____________________
% YES
______
1. Do you fear other’s negative judgement if you can’t begin urination?
91.7
2. Do you ever feel embarrassed when having urination problems?
95.8
3. Do you tend to blush when having urination difficulty?
46.2
4. If others are close by, do you become self-conscious and self critical
when having problems urinating?
96.2
5. Do you sweat, tremble, have a dry mouth or heart palpitations when
you fail to begin or complete urination?
50.8
__________________________________________________________________
What do you believe was the cause(s)?
(l) Anxiety
52.3
(h) Shyness
51.2
(j) Embarrassment from failing to urinate successfully
48.0
(k) Low self esteem
36.7
(b) Teasing
16.0
(d) Strict parenting
15.6
(c) Harassed at urinal
15.2
(a) Bullying
11.3
(g) Verbal abuse
8.6
(i) General blushing problem
3.1
(f) Physical abuse
2.7
(e) Sexual abuse
1.6
This can affect
Mental health
Physical health
Employment
Social Activities
Holidays
Relationships
Leading to
self imposed Social isolation
Gardner’s (2000) epilepsy study (N=4,500)
findings suggested two processes that may
be involved in this kind of withdrawal from
social interactions
IMPOSITION
LIMITATION
Just so you got the message!
Paruresis stops people peeing
It breaks up relationships
It limits social behaviour
Social Phobia ???
but now perhaps a
Social anxiety disorder
There is much we do not
know…hence…
We must rely on developing communications
Informing front line professionals
Establishing TRANSDISCIPLINARITY meetings
Developing research
3 P’s
Pre-disposing factors
Genetics
organic psychological
Precipitating factors
Trauma conditioning experiences
Perpetuating factors
Personality
avoidance strategies
We aim to pee
Alex Gardner
in
Suffering the
slings and arrows of
outrageous fortune
( Ed Bernie Warren)
Rudolphi press
http://www.interdisciplinary.net/publishing/idp/eBooks/shhindex.html